Danish researchers have found that diabetes education administered in a group setting does not improve the glycemic control of patients with diabetes more than individual counseling.

“On the contrary, the mean glycated hemoglobin (HbA1c) level decreased significantly more among participants in the individual counseling group,” say Eva Vadstrup (Bispebjerg University Hospital, Copenhagen) and team.

They add that cardiovascular (CV) risk factors such as “weight, waist circumference, and blood pressure (BP) decreased significantly compared with baseline values in both groups.”

The researchers assessed the level of glycemic control and CV risk among 143 adults with diabetes at baseline, and after a 6-month individual counselling (n=70) or group-based rehabilitation (n=73) program.

Both programs were taught by a nurse, dietician and podiatrist, and consisted of education on the pathophysiology of diabetes and blood glucose self-monitoring techniques, in addition to advice on the management of diabetes using medication, diet, and exercise.

In all, 87% of the patients in the group-based rehabilitation and 82% of the patients in the individual counseling group completed the 6-month programs.

As reported in the journal Patient Education and Counseling, both groups had a slight improvement in glycemic control at 6 months. This improvement was greater among the patients who received individual counseling than those in the group-based rehabilitation group, with a mean HbA1c reduction of 0.6% and 0.3%, respectively.

In addition, by the end of the programs both groups experienced a similar degree of improvement in CV risk factors, namely weight, waist circumference and systolic BP, with a mean weight loss of 2.0 kg and 2.1 kg, waist circumference reduction of 1.8 cm and 2.0 cm, and systolic BP reduction of 6 mmHg and 5 mmHg, among the patients in the individual and group programs, respectively.

Interestingly, Vadstrup et al found that despite the similar outcomes, the group-based intervention required twice as many personnel resources as the individual counseling program.

They advise against the broad implementation of such group-based interventions in preference to individual diabetes education at present.

“Further research should address the ways to modify and reorganise program content,” the researchers conclude, advising the consideration of “alternative strategies to achieve larger improvements, particularly in the light of the increasing prevalence of Type 2 diabetes.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

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UK researchers report that glycated hemoglobin (HbA1C) levels do not accurately reflect the glycemic control of diabetic patients who receive intravenous (iv) iron and erythropoietin-stimulating agents (ESAs) for co-existing chronic kidney disease (CKD).

Indeed, HbA1C levels can fall during treatment with these agents, therefore health professionals should seek out additional methods “for measuring glycemic control such as capillary glucose testing and continuous glucose monitoring (CGM),” say the researchers.

They suggest glycated albumin as a suitable alternative to HbA1C as it reflects glycemic control with similar accuracy in patients with iron deficiency and pre-ESA compared with patients post-therapy.

Jen Ng, from Hull York Medical School, and team studied 30 diabetic patients with moderate to end-stage CKD who underwent iv iron therapy alone (n=15) or with ESA (n=15).

HbA1C levels were measured at baseline and after a mean follow-up period of 16.4 weeks. Seven-point daily glucose was also measured three times a week during the study period along with CGM lasting at least 48 hours on each occasion.

As reported in the journal Diabetes Care, Ng and team found that mean HbA1C levels fell significantly among patients receiving iron alone and among those receiving both agents, from 7.40% and 7.31% at baseline to 6.96% and 6.63% at study end, respectively.

Mean blood glucose, however, did not change significantly among either patient group. Patients taking iron alone had mean blood glucose levels of 9.55 mmol/l at baseline and 9.71 mmol/l at study end, and those taking iron and ESA had blood glucose levels of 8.72 mmol/l at baseline and 8.78 mmol/l at study end.

Both iron and ESA treatment led to significant increases in hemoglobin and hematocrit levels, but this was not associated with the fall in HbA1C levels noted during treatment.

The researchers conclude: “At a time when self-monitoring of blood glucose is being discouraged, especially in non-insulin-treated patients, regular capillary glucose measurements, and the concurrent use of CGM if available, seems essential in order to accurately assess glycemic control in this group of patients.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

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Aggressive glucose lowering treatment to current target glycated hemoglobin (HbA1c) levels increases the incidence of severe hypoglycemia and fails to reduce the risk for vascular events compared with treating to more moderate targets, results of a meta-analysis indicate.

“Current guidelines recommend a target HbA1c level of 7.0% or less for most patients with diabetes,” note Meng Wei (Shanghai Jiao Tong University, China) and associates.

“Some believe that the lower the HbA1c level, the lower the risk for either microvascular or macrovascular complications,” say the authors. “However, this belief is not based on a systematic review of the available evidence.”

Accordingly, Wei and team searched various literature databases for randomized, controlled trials that compared vascular outcomes with intensive versus standard glycemic control in individuals with Type 2 diabetes.

The authors identified eight relevant studies, including the ACCORD and UKPDS trials, involving a total of over 32,000 patients.

In three studies where the intensive glycemic control target HbA1c was <7.0% compared with 7.0??”8.5% in the standard therapy group, there was no difference in combined macrovascular events, cardiac events, or stroke between the two treatments, nor in the microvascular endpoints of nephropathy, retinopathy, or neuropathy. However, there was a higher rate of hypoglycemia among intensively treated than in standard therapy patients (relative risk [RR]=2.34).

Meanwhile in five studies in which target HbA1c levels ranged from 7.0% to 7.9% in intensively treated patients compared with 7.6% to 9.4% in patients receiving standard therapy, there was again no difference between groups in macrovascular events, but lower rates of nephropathy (RR=0.43), retinopathy (RR=0.68), and autonomic neuropathy (RR=0.56) were observed with intensive therapy in two, three, and one study, respectively. These reductions in microvascular events apparently occurred without any increase in hypoglycemia rate, which was found to be no different between treatment groups in three studies.

Writing in the journal Nutrition, Metabolism, and Cardiovascular Diseases, the authors say that their findings are robust, as all data came from well-designed and conducted trials.

They note, however, that the participants in the studies were relatively young, with an average age of 59 years, and almost all had had diabetes for many years.

The researchers therefore say: “It is still unclear whether the conclusions of this analysis are applicable to older people and to patients with newly diagnosed Type 2 diabetes mellitus.”

They add: “In the future, we need more large-scale studies enrolled with more older patients or patients with newly diagnosed Type 2 diabetes mellitus.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2009

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When self-monitoring of blood sugar levels was first introduced, health care practitioners believed glucometers would be useful to educate people with type 2 diabetes. How? Well they thought by type 2 diabetics checking their sugar levels after eating carbohydrate foods, or exercising, they would learn “a good pattern of behavior”. However, many studies have found this did not happen.

There appears to be a lot of controversy as to whether diabetics who self-monitor actually see an improvement in their glycemic control. Apparently many people check their levels three or four times a day but then make no changes in their eating plan when their results are abnormal. Many studies investigating the value of self monitoring of blood sugars in diabetics whose levels are controlled by diet or oral medications, have not shown that this testing leads to improved diabetic control.

As type 1 and type diabetes is a condition where the main problem is elevated blood sugar levels, it seems there is value in being able to measure your blood sugars and discover how it is best kept under control. One good reason to know your sugar level is under control is this: the connection between high blood sugar levels and those diabetic complications!

Research shows neuropathy appears to come about when your blood sugars remain over 140 mg/dl (7.8 mmol/l) for two hours or more… this is when you are at the pre-diabetic stage. Actually many type 2 diabetics at the time of diagnosis have detectable neuropathy… this is due to the fact most diabetics have had elevated blood sugars for ten years prior to diagnosis. The blood glucose reading to confirm a diagnosis of type 2 diabetes is 200 mg/dl (11.1 mmol/l).

What is your self monitored blood sugar target?

Many diabetics have the following target but check with your health care practitioner and discuss the best levels for you. Sometimes targets change as you mature or complications develop.

• fasting BSL or pre-meal… between 90 and 130 mg/dl (5 and 7.2 mmol/l)
• one or two hours following your meal… less than 180 mg/dl (10 mmol/l)
• before going to bed… between 110 and 150 mg/dl (6.1 and 8.3 mmol/l)

Self monitoring gives you the ability to make choices about the foods you eat, and which physical exercise you should participate in to help lower your blood sugar levels. Always write your results in a logbook along with details of what you were doing at the time, for example swimming, hiking or drinking alcohol at a party.

A novel fixed-dose combination tablet of repaglinide plus metformin provides comparable glycemic control to a rosiglitazone plus metformin tablet, show results from a phase III study.

Combining oral agents into fixed-dose combination tablets offers potential increased convenience for patients and increased compliance with therapy.

Philip Raskin (University of Texas Southwestern Medical Center, Dallas, Texas, USA) and colleagues compared the efficacy and safety of the recently-approved repaglinide/metformin fixed-dose combination tablet with an existing rosiglitazone/metformin formulation.

In the 26-week study, 561 individuals with Type 2 diabetes not adequately controlled with mono- or dual oral antidiabetes medication were randomized in a 1:1:1 fashion to a repaglinide/metformin fixed-dose combination tablet either twice, or three times daily, or a rosiglitazone/metformin fixed-dose combination tablet twice daily.

The study was designed to test primarily whether treatment with the repaglinide/metformin single-tablet combination is noninferior to treatment with a rosiglitazone/metformin tablet as measured by changes in glycated hemoglobin (HbA1c), and secondly that treatment with repaglinide/metformin twice daily is noninferior to three times daily treatment.

“The repaglinide/metformin fixed-dose combination was shown here to be noninferior to rosiglitazone/metformin,” report the authors in the journal Diabetes, Obesity and Metabolism.

Final changes in HbA1c were not significantly different between the repaglinide/metformin and the rosiglitazone/metformin treatment arms, although reductions were observed earlier with repaglinide/metformin.

In contrast, rosiglitazone/metformin showed significantly greater reductions in fasting plasma glucose at weeks 18 and 26 than repaglinide/metformin.

The authors attribute this observation to the mechanisms of action of the two compounds. An insulin sensitizer such as rosiglitazone is more likely to improve fasting plasma glucose levels, whereas an insulin secretagogue such as repaglinide taken at mealtime is more likely to improve postprandial glucose excursions.

Rosiglitazone/metformin had a mostly adverse effect on lipid profiles. Triglycerides, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol all increased in this group, while the same parameters all decreased or were essentially unchanged during treatment with repaglinide/metformin.

As expected, hypoglycemic episodes were more frequent with repaglinide/metformin than rosiglitazone/metformin (38.8% vs 10.2%, respectively), although there were no episodes of severe hypoglycemia.

In the rosiglitazone/metformin group, peripheral edema was reported in 6.5% of individuals, but in only 2.1% of individuals in the repaglinide/metformin group. Overall adverse event profiles were comparable between treatment groups.

“This new repaglinide/metformin fixed-dose combination twice daily had efficacy comparable to that of the rosiglitazone/metformin fixed-dose combination twice daily currently in clinical use,” conclude the authors.

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a part of Springer Science+Business Media. © Current Medicine Group Ltd; 2009

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